Multiple tumors on the pleura with pleural effusion mimicking malignant mesothelioma

  • Hisanori Machida
    Affiliations
    Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi 780-8077, Japan
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  • Keishi Naruse
    Affiliations
    Division of Pathology, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi 780-8077, Japan
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  • Tsutomu Shinohara
    Correspondence
    Corresponding author at: Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan.
    Affiliations
    Department of Clinical Investigation, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi 780-8077, Japan

    Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
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Published:October 26, 2021DOI:https://doi.org/10.1016/j.ejim.2021.10.012
      A 68-year-old male presented with left chest pain and was referred to our hospital due to left-sided pleural effusion on a chest X-ray (Fig. 1 A). Initial laboratory data included a white blood cell count of 5650/μL and a C-reactive protein level of 0.36 mg/dL. CT during drainage of bloody effusion showed multiple tumors on the left chest wall and diaphragm, and residual effusion on the dorsal side, without hilar or peripheral lung lesions (Fig. 1B, C). No extrathoracic tumors were detected. Although effusion cytology was positive for malignancy, the histological type could not be determined even with cell block specimens. Thoracoscopy was performed for biopsy and demonstrated that all tumors were on the parietal pleura, but not the visceral pleura, and had poor continuity (Fig. 1D). Pathological examinations revealed small round tumor cells with dense nuclei and a large nuclear/cytoplasmic ratio, appearing as a pseudo-rosette formation (Fig. 1E). Immunocytochemical study demonstrated that the tumor cells were stained positive for specific neural differentiation markers such as CD99, CD56, synaptophysin and neuron-specific enolase (NSE) (Fig. 1F) .
      Fig 1
      Fig. 1Radiological findings (A: chest X-ray, B, C: CT), thoracoscopic photograph (D) and histology of a biopsy specimen (E: H&E staining, F: immunohistochemical staining). (A) Left-sided pleural effusion on admission. (B, C) Multiple tumors on the left chest wall and diaphragm observed during effusion drainage. (D) Tumors on the parietal pleura, but not the visceral pleura, showing poor continuity. (E) Small round cells with dense nuclei and a large nuclear/cytoplasmic ratio appearing as a pseudo-rosette formation. (F) Positive staining for neuron-specific enolase (NSE).
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